Questions: Call 1-855-404-6752 or visit us at www.SouthCarolinaBlues.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at
www.dol.gov/ebsa/healthreform or www.cciio.cms.gov or call 1-855-404-6752 to request a copy. 1 of 8
MSP Silver 1 – NA >300%
:
Blue Cross Blue Shield Silver 1, a Multi-State Plan
Coverage Period: 1/1/2014 – 12/31/14 Coverage for: Single | Plan Type: EPO Summary of Benefits and Coverage: What this Plan Covers & What it CostsThis is only a summary.
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.SouthCarolinaBlues.com or by calling 1-855-404-6752.Important Questions Answers Why this Matters:
What is the overall deductible?
$
prescription drugs or in-network doctor’s office visits. 2,500 per person. Doesn’t apply to preventive care, Copays do not count toward the deductible.You must pay all the costs up to the deductibleamount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services? No.
You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.
Is there an out–of–pocket limit
on my expenses? Yes. $6,000 per person for in-network providers
The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out–of–pocket limit?
Premiums; charges in excess of the Allowed Amount; amounts exceeding any Maximum Payments for benefits; or any expense not allowed according to any provisions of this coverage.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Does this plan use a network of providers?
Yes. For a list of in-network providers, see www.SouthCarolinaBlues.com or call 1-800-810-2583
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to see a
specialist? No. You don’t need a referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan
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● Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
● Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
● The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
● This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common
Medical Event Services You May Need Your Cost if You Use an In-network Provider
Your Cost if You Use an Out-of-network
Provider
Limitations & Exceptions
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or
illness $25 copay/visit 100% Does not include surgery, outpatient lab and X-ray services (except for standard plain film X-rays), second surgical opinion, dialysis, chemotherapy, radiation therapy specialty drugs, endoscopies and imaging. Your cost if at designated Native American Providers $0.
Specialist visit $50 copay/visit 100%
Other practitioner office visit Not covered Not Covered –––––––––––none––––––––––– Preventive care/screening/immunization No charge Not Covered –––––––––––none––––––––––– If you have a test
Diagnostic test (x-ray, blood work) $200 copay/visit, then 30% coinsurance 100% Your cost if at designated Native American Providers 0% coinsurance. Imaging (CT/PET scans, MRIs) $200 copay/visit, then 30% coinsurance 100% No benefits if not preapproved. Your cost if at designated Native American
Providers 0% coinsurance.
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.SouthCarolinaBlues .com.
Generic drugs
$10 copay/prescription (retail)
$14 copay/prescription (mail-order)
Not covered
Covers up to a 90-day supply at mail-order pharmacy. Covers up a 30 or 90-day supply at retail pharmacy, subject to 3 copays. Your cost if at designated Native American Pharmacy $0. Preferred brand drugs
$35 copay/prescription (retail)
$95 copay/prescription (mail-order)
Not covered
Non-preferred brand drugs
$100 copay/prescription (retail)
$270 copay/prescription (mail-order)
Not covered
3 of 8 Common
Medical Event Services You May Need
Your Cost if You Use an In-network
Provider
Your Cost if You Use an Out-of-network
Provider
Limitations & Exceptions
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery
center) 30% coinsurance 100% Hysterectomy or septoplasty must be preapproved or no benefits. Cosmetic surgery is not covered. Your cost if at designated Native American Providers 0% coinsurance.
Physician/surgeon fees 30% coinsurance 100%
If you need immediate medical attention
Emergency room services $200 copay/visit, then 30% coinsurance
Facility charges only – $200 copay/visit, then 30% coinsurance. All other charges – 100%
Your cost if at designated Native American Providers 0% coinsurance. Emergency medical transportation 30% coinsurance 100%
Urgent care $25 copay/visit 100%
Does not include surgery, outpatient lab and X-ray services (except for standard plain film X-rays), second surgical opinion, dialysis, chemotherapy, radiation therapy specialty drugs, endoscopies and imaging. Your cost if at designated Native American Providers $0.
If you have a hospital stay
Facility fee (e.g., hospital room) $200 copay/visit, then 30% coinsurance 100%
No benefits if not preapproved. No benefits for human organ/tissue transplant if not preapproved and at designated provider. Your cost if at designated Native American Providers 0% coinsurance.
Physician/surgeon fee 30% coinsurance 100%
No benefits for human organ/tissue transplant if not preapproved and at designated provider. Your cost if at designated Native American Providers 0% coinsurance.
4 of 8 Common
Medical Event Services You May Need
Your Cost if You Use an In-network
Provider
Your Cost if You Use an Out-of-network
Provider
Limitations & Exceptions
If you have mental health, behavioral health, or substance abuse needs
Mental/Behavioral health outpatient
services 30% coinsurance 100%
No benefits if not preapproved. Your cost if at designated Native American
Providers 0% coinsurance. Mental/Behavioral health inpatient
services $200 copay/visit, then 30% coinsurance 100% Substance use disorder outpatient
services 30% coinsurance 100%
Substance use disorder inpatient services $200 copay/visit, then 30% coinsurance 100%
If you are pregnant Prenatal and postnatal care 30% coinsurance 100% Your cost if at designated Native American Providers 0% coinsurance. Delivery and all inpatient services $200 copay/visit, then 30% coinsurance 100%
If you need help recovering or have other special health needs
Home health care 30% coinsurance 100%
Limited to 60 visit/year. No benefits if not preapproved. Your cost if at designated Native American Providers 0%
coinsurance. Rehabilitation services $200 copay/visit, then 30% coinsurance 100%
Outpatient physical, occupational and speech therapy limited to 30 visits/year combined. No inpatient benefits if not preapproved. Your cost if at designated Native American Providers 0%
coinsurance. Habilitation services $200 copay/visit, then 30% coinsurance 100%
Skilled nursing care $200 copay/visit, then 30% coinsurance 100%
Limited to 60 days/year. No benefits if not approved. Your cost if at designated Native American Providers 0% coinsurance.
Durable medical equipment 30% coinsurance 100%
Excludes repair of, replacement of and duplicate. No benefits if not preapproved when cost is $500 or more. Your cost if at designated Native American Providers 0% coinsurance.
Hospice service 30% coinsurance 100%
Limited to 6 months/episode. No benefits if not preapproved. Your cost if at designated Native American Providers 0% coinsurance.
5 of 8 Common
Medical Event Services You May Need
Your Cost if You Use an In-network
Provider
Your Cost if You Use an Out-of-network
Provider
Limitations & Exceptions
If your child needs dental or eye care
Eye exam $25 copay Not covered Limited to one eye exam per benefit period
Glasses $50 copay Not covered Limited to once per benefit period for frames and lenses. Contacts covered only when medically necessary
Dental check-up $0 Not covered –––––––––––none–––––––––––
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) • Acupuncture
• Bariatric Surgery • Chiropractic care • Cosmetic Surgery • Dental Care (Adult) • Hearing aids
• Infertility treatment • Long-term care
• Other practitioner office visit • Private Duty Nursing
• Residential and custodial care
• Routine eye care (Adult) • Routine foot care • Varicose vein treatment • Weight loss programs.
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • Non-emergency care when traveling outside the U.S. See
6 of 8
Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:
• You commit fraud
• The insurer stops offering services in the State • You move outside the coverage area
For more information on your rights to continue coverage, contact the insurer at 1-800-868-2500, extension 46401. You may also contact your state insurance department at South Carolina Department of Insurance, Post Office Box 100105, Columbia, SC 29202-3105, Telephone: 800-768-3467.
Your Grievance and Appeals Rights:
If you have a compliant or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact the South Carolina Department of Insurance, Consumer Services Division, Post Office Box 100105, Columbia, SC 29202-3105, telephone: 803-737-6180, Email: consumers@doi.sc.gov.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage”. This plan or policy does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.
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About these Coverage
Examples:
Having a baby
(normal delivery)
Managing type 2 diabetes
(routine maintenance of a well- controlled condition)
These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.
Amount owed to providers: $7,540 Plan pays $3,440
Patient pays $4,100
Amount owed to providers: $5,400 Plan pays $2,460
Patient pays $2,940
This is
not a cost
estimator
Sample care costs: Sample care costs:Hospital charges (mother) $2,700 Prescriptions $2,900
Don’t use these examples to Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 estimate your actual costs under Hospital charges (baby) $900 Office Visits and Procedures $700
this plan. The actual care you Anesthesia $900 Education $300
receive will be different from Laboratory tests $500 Laboratory tests $100
these examples, and the cost of Prescriptions $200 Vaccines, other preventive $100
that care will also be different. Radiology $200
Total $5,400
Vaccines, other preventive $40
See the next page for important Total $7,540
information about these
examples. Patient pays: Patient pays:
Deductibles $2,500 Deductibles $2,500
Copays $20 Copays $350
Coinsurance $1,430 Coinsurance $10
Limits or exclusions $150 Limits or exclusions $80
Total $4,100 Total $2,940
Questions: Call 1-855-404-6752 or visit us at www.SouthCarolinaBlues.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov or call 1-855-404-6752 to request a copy.
8 of 8 BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
Questions and answers about the Coverage Examples:
What are some of the assumptions behind
the Coverage Examples?
What does a Coverage Example show?
Can I use Coverage Examples to compare
plans?
• Costs don’t include premiums.
• Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or
preexisting condition.
• All services and treatments started and ended in the same coverage period.
• There are no other medical expenses for any member covered under this plan.
• Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in-network
providers. If the patient had received care from out-of-network providers, costs would have been higher.
For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.
Yes
. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.Does the Coverage Example predict my own care needs?
No
. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.Are there other costs I should consider when comparing plans?
Yes
. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.Does the Coverage Example predict my future expenses?
